Health Insurance & Affordable Care Act

Limitations Of New Health Plans Rankle Some Enrollees

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But along with consumers, lawmakers and regulators have begun to push back.

In California, managed care regulators are investigating Anthem and another insurer, Blue Shield of California, after receiving numerous complaints about access to doctors and hospitals.

Lawmakers in 22 states debated laws this year and last related to network adequacy, although the vast majority failed to pass, according to the National Conference of State Legislatures. In Washington state, administrative rules announced this spring require insurers to provide enough primary care doctors so enrollees can get an appointment within 10 days and 30 miles of their home or workplace. Directories of participating providers must be updated monthly.

“I have heard from many consumers … who were upset to find their health plan no longer included their trusted doctor or hospital … and some discovered this only after they enrolled,” Washington Insurance Commissioner Mike Kreidler said in an announcement of the rules in April.

Scrambling To Find Doctors

Brian Liechty of TCU Insurance in Plymouth, Ind., said he has helped “hundreds” of clients sign up for tightly managed plans – including Pippenger, when her work-based plan was discontinued.

“For the right person who is willing to go where they must and live with rules, it allows them to buy a health insurance policy they could never touch before,” he said. “So, there are some good things, but balancing it out, there are some equally bad things for people who previously had insurance.”

Patient advocates agree that managed care can be done well but caution that some policies could leave patients scrambling to find doctors – and on the hook for thousands of dollars if they go out of network.

“If highly specialized care -- an academic medical center or a cancer center -- is not available in a plan’s network … some plans will send you to an out-of-network provider, but it’s not required,” said Laura Skopec, senior policy analyst at the cancer action network.

Going out of a managed care plan’s network often means patients foot the entire bill, which can be financially devastating in cases of serious illness. In other types of insurance plans, a portion of the out-of-network bill might be covered, but consumers still face sharply higher costs than if they see a network provider.